ON THE ETHICS OF CONSTRUCTING

REALITIES
Harry Korman

ABSTRACT: The author describes the successful use of Solution-Focused Brief Therapy intervention with an 11-year-old female who had
been hospitalized for two weeks because she could not walk. He raises
some ethical questions about the use of diagnosis "if, or when, we
know different and maybe faster and simpler ways to find out what
can be helpful?"
KEY WORDS: Solution-Focused Brief Therapy; medical treatment; paralysis; psychiatry.

A man comes to his tailor to try on his new suit, and complains that the fit isn't perfect over the back. The tailor
makes him lean forward and look again, and in this position
the suit looks fine. The man complains about the arm and
the tailor makes him lift his arm, and a similar problem with
the left leg is solved by bending it, and finally the man is
satisfied and walks out in his new suit.
Bent forward, one arm in the air and one leg crooked, he
limps down the street. Two men standing down the road see
him coming and one of them says to the other, "Gee, have you
seen that, I wouldn't want to be as handicapped as that." The
other one looks, nods his accord and says, "Me neither, but
he certainly has an amazingly talented tailor."
In the western world today, we look at emotional phenomena as
if they were physical (in the same way as fever, rash and a sore
throat). We try to classify, explore, and explain these phenomena in
basically the same way as when exploring medical disease. The purpose of the classifications thus created is for the physician/therapist
Harry Korman, MD, Drottninggatan 6c, S-212 11 Malmoe, Sweden.
Contemporary Family Therapy, 19(1), March 1997
c 1997 Human Sciences Press, Inc.

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to know what to do. There is a basic belief that from the way we
group "symptoms" together and call them something: hysteria, neurosis, schizophrenia, alcoholism, enmeshed families, etc., will emerge
knowledge of specific treatments, psychological or biological, that will
be tailored for the underlying condition causing the specific "illness"
thus named. We use the same methods as in medicine, and these
methods are not thought of as altering or changing what we are looking at. A sore throat is a sore throat, anxiety is anxiety, schizophrenia
is schizophrenia, and the conditions exist independently of how we
observe/describe and talk about them. The behaviors thus classified
are always indicative of an "underlying" problem, disturbance or disease. "Deviant" behaviour always has underlying causes, individual,
contextual, biological, or different combinations of these and finding
these causes is essential for treatment.
The disease model (Figure 1) is simple to understand. Someone
presents with a problem, say, a sore throat The physician examines
the patient, determines the underlying causeinfectionand delivers the appropriate treatment.
At the present level of knowledge in psychiatry it is acknowledged that we may not know the "real causes" of the underlying "diseases," but it is assumed that with more research we will, and this
knowledge will bring about specific treatments. This may be right,
but it may also be wrong. It is possible that we are on the wrong
track. It could be that problems arise and exist in language both

FIGURE 1
The Disease Model

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as result, reason, cause and effect as proposed by the post-modern

thinkers. If this is the case our efforts today will come to a dead-end.
We can only see what we can describe as we can only describe
what we can see. We make sense of the world and of what is happening from how we describe it. The theory we use to make sense of the
world decides what we are looking for and when we ask questions we
do it to get to the facts that fit with the theory. ('The suit fits fine, just
bend a little here and there and you'll see for yourself).

A CASE
Lena is 11 years old and has been in the hospital for a fortnight
because she cannot walk. She has been through thorough examinations during those two weeks, and all known possible physiological
reasons for her inability to walk have been excluded.
I am called to the pediatric ward as the child psychiatric consultant, and it is clear from the referral sheet that Lena is considered to
be a "child psychiatric case":
Strong suspicion of conversion syndrome. Doesn't seem to be
saddened by her condition. Talks with a smile about not being able to walk.
I was once trained in traditional psychiatric diagnostics and assessments. Some 15 years ago I tried learning structural and strategic family therapy, and I have now for nine years done solution-focused therapy in child psychiatry and outpatient drug dependency
treatment.
Twenty years ago I would have started the interview with Lena
and her mother by trying to penetrate her background and actual
social situation, and I would have tried looking thoroughly for 2-3
weeks before the interview to find the reason her unconscious decided
at that time it was better not to walk. I would have looked at issues
concerned with primary and secondary gain and looked into questions
of dependency.
Fifteen years ago I would have started by trying to get an idea of
how she and her mother and other important people around her
looked at the situation. I would have gotten an enactment started
between her and her mother to get an idea about that relationship,
and I would have asked many questions about her father in order to

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get a clear picture of boundaries and holons in order to understand

how the problem fit in the family structure.
With both theories/methods I would have made an effort to get an
understanding of the cause for her conditionan explanation, the
first being "she has a hysterical palsy" determined by a certain organization of her psyche, the second being a structural diagnosis of the
family "enmeshed, blurred boundaries" etc.
Both theories/methods would have permitted a child psychiatric
assessment (in Sweden)an explanationto be put in my file about
her. Both methods would also have guided the treatment. The first
would most probably have led to long-term individual therapy; the
second to structural or strategic family therapy. Diagnostics done
within a certain model of thinking normally leads to treatment within
that model.
THE INTERVIEW
When we (an intern and myself) arrive in the pediatrics ward,
Lena is in her bed and on the chair next to her is her mother. They
both smile politely while we sit down and introduce ourselves as doctors from child psychiatry. I then lift my head toward Lena and ask,
"What are you good at?"
She looks at her mother who doesn't say anything, turns to me
and wonders, "Do you mean at school, or?"
"Yes," I say. She thinks for awhile, and then answers, "Drawing."
She thinks for a while longer, looks at her mother again, and continues, "It's fun to paint too, and I am good at English." I add, "What
else?" and she answers, "Bicycling." Turning to mother I ask, "What
else is she good at?"
"She is good at taking care of her money. She is good at helping
out at home and she is very good at house-cleaning."
I mumble, "Good," take notes, and turn to the girl again, "What is
she good at," I ask as I point to mother. "She is good at ruining her
hair," says Lena, and mother laughs under a head that obviously
comes directly from the hairdresser (permanent), and Lena laughs
also. I smile and say, "I understand what you mean," and she smiles
back at me.
"Now I want to ask you a very difficult question," I say. "Suppose
you go home today and tonight you go to bed and you go to sleep.
While you're asleep a miracle happens (she looks questioningly at me,

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so I add) "wonder" (and she nods in understanding)"and tomorrow

the problem that made you come here is gone." Lena nods and I continue, "But as you're asleep when the wonder happens, you won't
know it happened. What is different tomorrow that will make you
think that there has been a wonder?"
She thinks for a long time, and then recounts that she will get
up, wash herself, and get dressed. She will then walk (she stresses
the word walk which in Swedish means both go and walk) to the
kitchen, and she will have her ordinary breakfast. She will then go to
school and on the way to school she will meet and accompany her
friends.
I nod and ask, "How will they react when they see you're walking?" She immediately answers, "They'll be happy." I wonder if they
will be surprised as well, and she confirms, thinks for a few seconds,
and recounts that on the way to school she and her friends will surely
play, jump in the puddles, and they will have to run the last few
hundred meters to school in order not to be late "because it's always
like that."
I ponder for a second if she's always late for school or if she always runs the last few hundred meters or both, and I then decide
that this distinction is not relevant for the purpose of my interview.
So I continue, "What else will be different?"
During class things will not be different, because one just sits
anyway, but during the breaks she will play with her friends, she will
jump with the skipping rope, play hide and seek, and in the afternoon
after school she will go roller-skating, and everyone will be very
happy because she started walking again and can join in the play.
To a series of supplementary questions detailing how friends,
parents, grandparents, and teachers will react and behave, she describes that she will be proud of herself, her friends will be happy,
and her parents and grandmother (who has been very worried) will be
very proud of her.
She gets increasingly excited, seats herself more upright in her
bed, and about 25 minutes into the interview suddenly says, "I have
already started practicing!"
"How?" I ask, and she shows how she has been practicing stretching and plying her legs using her arms. I wonder if she already got so
far that she dared trying to stand on "her leg." She answers "no," but
accepts a bit hesitantly that I lift her out of her bed and put her on
the floor where she succeeds in taking a couple of staggering steps.
"Wow!" I exclaim and applaud her. "This is amazing. You can already

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start feeling proud of yourself:" She smiles shyly and looks at her
mother who is also applauding, even if not as enthusiastically as I
am. She smiles again and I help her get back to her bed.
"On a scale from 1 to 10 where 10 means you are certain that you
want to work very hard to solve this problem, where are you at?" I
ask, and she answers "10."
"How certain are you that you will solve it?
"Seven," she answers. To the same question mother answers 10.
After this we speak briefly about things seemingly going in the
right direction, and I then explain that I want to take a break to
think and discuss with my colleague how we see the situation and to
think about if we have any idea on what could be helpful, and we
leave the room.

THE CONFUSION
Everybody knows about dreams. While dreaming the dream is
the reality, and no matter how bizarre the dream may seem afterward, it is only very rarely possible to "reality-test" the content of a
dream while asleep.
Coming out of the room there is only one thought in my head.
"This cannot be hysteria, there isn't even a shred of 'la belle indifference.' Nothing has come out that can be seen as a triggering factor.
There are no personality traits pointing toward hysteria. This girl
wants to walk on her legs and is working hard for it. The pediatricians must have missed something!" I tell this to the accompanying
intern and together we start looking through her medical records.
Have they thought of everything?
It is a thick file and we can see that she has been scanned by
every possible machine, and every bodily fluid has been drawn and
examined. The somatic colleagues have looked for signs of very rare
and uncommon causes for palsies, and finally we have to conclude
that we are not more clever than our colleagues in orthopedia and
pediatrics.
I am very confused. Psychiatry is supposed to be my area of expertise and I have to give some kind of answer to these colleagues of
mine. Maybe something is slipping my mind, but at that moment I
can't think of what. All I can think of is that I haven't found anything
that speaks for a psychiatric diagnosis, and I'm falling into the same
trap that we sometimes accuse our colleagues in somatic medicine of

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falling into, namely, when you've excluded every possibility that there
may be a somatic reason, you then conclude that the illness is a psychiatric one. I am embarrassed. The only relief and bearing for me is
that I notice in the file that the physicians see her differently than I
do. Phrases like "not concerned by her serious symptom. Smiles when
she talks about not being able to walk" do indicate that there may be
signs of at least 'la belle indifference,' and I recall that the same thing
was said on the referral sheet.
So eventually I make up my mind. The solution-focused interview
did seem all right, and I decide that it must be relevant in at least
some way, so in order to finish the session I go back to my theory
about therapy, and I make my "therapy-diagnosis" from within the
framework of "therapy as a system" (de Shazer, 1988).
1. She told me she has a problem.
2. She told me that she wants to do something (at least work
hard) to solve the problem.
3. She described what she has already started doing that works.
4. Evaluating the relationship, I believe that if I ask her to do
something it is probable that she will do it if it makes sense to
her.
My map says: As she has already started doing something that
has led to progress, it could be helpful for her to do more of it.
I rapidly prepare a summing-up of the session and return to the
room where mother and Lena look at us expectantly.
I turn to mother first and say, "I am impressed by your daughter.
Her helpfulness at home, that she can already take care of her
money, that she has so many and broad interests, and her strong will
to do something about this very serious problem. But I am most impressed by the fact that she has already taken the first steps. That
she has found a way to practice that works for her and pays off. " I
turn to the girl who is shining. "I would like to suggest that you go
home today, do you want that?" She nods. "At home you continue to
practice in exactly the same way you started here, and when you feel
ready for it, you start going to school again. Then I want to see you at
my office in the next building over there in three days. Is that OK?"
She nods, seems satisfied with that, and we set up an appointment.
In what consisted my confusion? At the moment I couldn't understand why I didn't see any "signs" of hysteria. At least I ought to have

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seen "la belle indifference." You may see cases of hysteria in psychiatric praxis without "la belle indifference," and it may exist with certain very heroic cancer-patients (American Psychiatric Association,
1980), but my clinical experience has consistently been seeing those
typical traits of character and the signs of hysteria with conversionhysteria patients. So I was very confused.
A couple of weeks after I saw her the second time I realized what
had gone wrong in my head. I had thought of "la belle indifference" as
a property of a person, as a trait of character. (If you have a hysterical
palsy, you must also have "la belle indifference"if the man is very
handicapped he has a very good tailor.)
My realization was that of course I couldn't see "la belle indifference"the sign of illness, such things are relational phenomena,
not properties or characters of persons.
To claim that there is (exists) "la belle indifference" I have to
examine the girl's relationship to her symptom. I am then part of a
triangle that could be visualized like Figure 2, and I am of course a
part in creating what I am looking for. But I did not examine her
relationship to her problem. We were not talking about her problem.
We were talking about her goal. Together we were co-creating her
preferred future. It appears in Figure 3.

FIGURE 2
La Belle Indifference: Symptoms as Relational Properties,
Not Properties of Persons

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FIGURE 3
Patients Goal: Co-creating Patients Preferred Future

In the relationship thus created there isn't a shred of la belle

indifference. On the contrary, this little girl is very eager to walk. In
our conversation her eagerness seems to grow in relation to the fantasy she has about what will happen in our co-created imagined future about her without the problem.
With this particular casewithin that sessionI am certain
that it would have been impossible for me to do both things: Create
the information necessary to make the diagnosis of hysteria and thus
have her display beautiful indifference, and then have her change
into forceful, committed, and strong-willed in a "struggle" to get well.
One type of relationship excludes the possibility of the other existing
at the same time. Had I started to examine her relationship with her
problem she would have become "hysterical." Talking about her preferred futureand she starts walking within the session.
Of course, one can only speculate as to what would have happened had I done an assessment in a more traditional way. Her paralysis would probably have regressed very quickly no matter what
(most diseases heal in spite of treatment). This is at least suggested
by her already started training (or was this also co-created in the

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session?), but it's easy to imagine Lena and her family in therapy for
a long time (which of course is not certain to be a bad thing).
I saw this girl only once more, three days later. She came running in the corridor toward my room. The wonder as she had described it, occurred in minute detail the morning after she was discharged. It was as if she had only to follow her own manuscript and
everyone else did.
During a rather short interview I asked her how certain she was
that she would be able to continue walking even if it would sometimes
become difficult, and she answered "Nine." Mother answered "Seven."
I wondered what made her so sure, and she answered, "Well, 'cause
next time I am in pain I will know what to do." Mother and I agreed
that this was good enough and that they would call if they needed to
in the future. One year later I phoned mother and she described a
positive development and no problems.
The theory governing how Lena, mother, the intern, and I construct a hypothetical future without the problem (many, many other
constructions are also possible within the therapeutic system) contains no elements that are dependent on the girl's personality, her
inner structures, or her family situation. The theory is only about coconstruction in the setting of the therapeutic interview. It is a theory
about therapy or better; a description of therapy, and it is not a theory about the people in therapy. Within that theory there exists a
nosology or classification that can be used to guide the therapist.
Within that frame and with its many limitations the theory is
coherent and consistent. One element depends on the other, and together the different parts form a whole, the same way such wholeness
is held together within other theoretical systems. Thus it becomes a
real alternative to traditional diagnostic thinking in the sense that it
helps us decide what to do, even though it does not help us decide
what's wrong with a certain person or a certain family system. It only
helps us decide what might be helpful.
So to get back to the story of the man leaving the tailors shop.
'The descriptions, done by the men looking at him, are true, and their
descriptions fit together. The man is very handicapped and he has a
very good tailor. There is inner coherence or fit between the different
parts of the descriptions; if he is handicapped he has a very good
tailor, or if he has a very good tailor he is very handicapped. The
different parts of the diagnosis fit together and are dependent on each
other, simply because one is always deduced from the other.
These men are not wrong. From their perspective the description
is correct, even if a description from other perspectives would be di-

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ametrically opposite. This man is not handicapped, at least not when

it comes to his body, and his tailor is definitely not a good tailor even
though he may be good at other things. If one part is true, then the
other one is true also, and if one thing is false the other is false also.

THE ETHICS OF IT
We cannot know how the world of this little girl is organized, or
how her family is organized, because they will organize themselves
within the limitations of the interviewer's theory. Within the theory of
the interviewer an inner coherence will exist (or be created). (Overinvolved mother, dependent girl, deduced family structures or psychic
structures that can explain her symptom.)
In most psychiatric settings in the world today therapists and
physicians conform to the standards of assessments and diagnosis
that are predominant in those settings. (This is also true for social
services.) Thus relationships are determined not from the possibilities
of the persons having problems, but from the theories that guide assessments and diagnosis. These theories may be right or wrong, but
as shown in the case above they will determine the existence and nonexistence of certain relationship patterns, and if we believe that the
conversations and relationships we have with our clients have some
effects on their life, we can only conclude that these theories can exclude certain possibilities for certain clients.
These theories also make it impossible to know for which clients
there exist other possibilities than those created within the assessment and diagnosis.
Very practically, should I have stopped the interview on goals
and directed it toward her problem in order to get some indications of
"la belle indifference," so that I could have put the necessary keywords into her file? Would it still had been possible to make the same
intervention? Would the result had been the same?
Is there a choice to be made? Can we continue to diagnose if, or
when, we know different and maybe faster and simpler ways to find
out what can be helpful?

REFERENCES
American Psychiatric Association (1980). Diagnostic and statistical manual of mental
disorders, 3rd ed. Washington, DC: Author,
de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York: Norton.